Adult Vital Signs Date
Chart Time: (24 Hour)
Eyes opening
4 Spontaneously
3 To speach
2 To pain
1 None
Best Verbal 5 Oriented
Response
4 Confused
GLASCOW COMA SCALE
3 Inappropriate
words
Tracheostomy =
T 2 Incomprehensible
sounds
1 None
Best Motor
Response 6
Obeys commands
5 Localise pain
4
Flexion withdrawal
Usually record 3 Flexion abnormal
the best arm
response 2 Extension
1 None
Total GCS
Pupils
++ Brisk Size
Right
+ Sluggish Reaction
- No Reaction Size
Lef
C Closed Reaction
Arms Normal Power
Mild Weakness
Record right (R) and Severe Weakness
lef (L) separately if
there is a difference Flexion
between the two sides Extension
No Response
Legs Normal Power
Mild Weakness
Record right (R) and
lef (L) separately if Flexion
there is a difference Extension
between the two sides
No Response
Resplratory rate ≥ 36
(breaths/min)
31 - 35
21 - 30
9 - 20
Write value in box
5-8
≤4
O2 Flow rate RA orL/min
O2 Sat (%) %
Blood Pressure ≥ 180
(mmHg)
170
160
150
140
130
120
110
100
90
80
70
Apply score to 60
systolic only
≤ 50
Heart rate ≥ 170
(beats/min)
160
150
140
130
120
110
100
90
80
70
(if hearts rate > 140 60
or < 40 write value
in vox
50
≤ 40
Temperature (°C) 40
39
38
37
37
36
35
4 hour urine ≥ 120
output if < 120ml 80 - 90
(write mL
total) ≤ 79
Rest
Pain Score
( 0 to 10 ) Movement
Respiratory rate
Systolic BP
Early Warning
Score ( EWS ) Heart rate
4 hour urin output
Level of consciousness
THE WELLINGTON ADULT VITAL SIGNS CHART
NEUROLOGICAL
Patien Label Here
MEDICAL STAFF : MODIFICATION TO EWS
if the patient is not for Medical Emerdency Team calls +/-
Noot For Resuctitation please document in the clinical record
and indicate be completing the box on the right & below
Any Early Warning Score (EWS) modification must be made by
a doctor and should be regularly reviewed by the primary
team.
Respiratory Rate
to
Systolic BP to
Heart rate to
4 hour urine output to
level of consciousness
Write the acceptable ranges outside which abnormal vital sigs are tolerated for
patient's clinical condition - the EWS will be 0
EWS KEY
0 1 2 3
777
MET
NURSING ACTION REQUIRED FOR PATIENTS
TRIGGERING EARLY WARNING SCORE
Early Warning Scores (EWS) should be calculated when any vital sign falls
into a coloured zone (see colour key above). Vital signs should be recorded
at the beginning of each shif with the ongoing frequency determined by
the patient’s clinical condition.
Any vital sign in the Dial 777 & state ‘Medical Emergency
orange zone or total
Team ' ( MET) : STAY WITH PATIENT
score 8 0r nore
Any vital sign in the
orange zone or total
score 6 - 7 IF TOTAL GCS Registrar review within 20 minutes
inform PAR nurse ( page 6785), House
DROPS BY 2 OR MORE Office and nurse in charge
OR IF MOTOR SCORE
DROPS BY 1
House Offi cer review with 60
Any vital sign in the
minutes: discuss with nurse in
gold zone or total
charge and inform PAR nurse
score 4-5
(page 6785).
Manage pain, fever or distress:
consider increasing frequency
Any vital sign in the gold of vital sign observations and
zone or total score 1 - 3
discussion with nurse in charge/
referral for review
CALL 77 MET FOR ANY PATIENT YOU ARE SERIOUSLY CONCERNED ABOUT
REGARDLESS OF VITAL SIGNS/EWS
At the time of referal to a House Officer, Register ot PAR nurse complete
an 'Activation of EWS sticker and place in the patient record.
If there is no timely response to your request for review escalate to the
next coloured zone.
NOTES
NOTES
LT VITAL SIGNS CHART
OGICAL
bel Here
DIFICATION TO EWS
NOT FOR MET
NOT FOR CPR
Doctor's name
Doctor's designation and
pager number
Date and time
h abnormal vital sigs are tolerated for the
on - the EWS will be 0
777
MET
RED FOR PATIENTS
WARNING SCORE
culated when any vital sign falls
e). Vital signs should be recorded
going frequency determined by
777 & state ‘Medical Emergency
m ' ( MET) : STAY WITH PATIENT
strar review within 20 minutes
m PAR nurse ( page 6785), House
Office and nurse in charge
Offi cer review with 60
es: discuss with nurse in
and inform PAR nurse
e pain, fever or distress:
er increasing frequency
sign observations and
sion with nurse in charge/
SERIOUSLY CONCERNED ABOUT
Register ot PAR nurse complete
place in the patient record.
quest for review escalate to the
zone.
ES
ES
